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Do we need to change the way we are thinking about mental illness? 13 May 2013

NO Simon Wessely, member of the Royal College of Psychiatrists

Next week the American Psychiatric Association is publishing its fifth take on the classification of psychiatric disorders, the DSM-5. Judging by the sound and fury, you might be forgiven for thinking that this is something radical – a great breakthrough in our struggle to better understand mental disorders, or alternatively a dastardly plot to extend the boundaries of psychiatry into everyday life and emotions at the behest of greedy drug companies. Or, if the position statement from the Division of Clinical Psychology (DCP) is to be believed, an attempt to emphasise the biological causes of mental disorders over the social and psychological.

In fact, it is none of the above. A classification system is like a map. And just as any map is provisional, ready to be changed as the landscape changes, so is classification. Our knowledge of the changing landscape can come from many sources. This week's Lancet, for example, highlights new research showing the genetic overlaps between several serious psychiatric disorders, which call into question the current boundaries between schizophrenia and bipolar disorders (genes matter, even if we don't yet fully understand how). I expect that the map of severe mental illness in DSM-6, when it appears, will have been redrawn and that it will be on the basis of a better biological understanding of those disorders.

But does that mean that, as the DCP is saying, psychiatry is gradually being taken over by the biologists, attempting to reduce human experience to the level of molecules and cells? The answer is an unequivocal no. Psychiatry is the study of the brain and the mind. Psychiatrists look at the whole person, and indeed beyond the person to their family, and to society. That is why even as a medical student I knew that psychiatry was for me – it was about biology, but it was also about psychology, and sociology, ethics, politics and much else. Psychiatrists react to the tired arguments about biology versus psychology in the same way as geneticists react to sterile debates about nature versus nurture – it's both. Mindless psychiatry is as unhelpful as brainless psychiatry, and the psychiatrist who ignores the social environment is, well, not a psychiatrist. Political decisions about the economy in, for example, Greece or Russia have had serious consequences on some, but not all, mental disorders.

So why the fuss about DSM-5? After all, it's hardly a good read – not the kind of book anyone will take on holiday – and it isn't the system of classification that we use over here in any case. In practice, most UK mental health professionals will barely notice much difference. Some diagnostic criteria will have improved, others less so, and no doubt there will be some "only in America" stories about the inevitable daft new category. But most of those in the business of helping those with mental disorders will be less concerned with what is in and what is out than with the reality of underfunded and overstretched services. The idea that we are part of a conspiracy to medicalise normality will seem frankly laughable as we struggle to protect services for those whose disorders are all too evident under any classification system.

Simon Wessely is a member of the Royal College of Psychiatrists and chair of psychological medicine at King's College London

YES Oliver James, author and clinical psychologist

A student friend of mine once started claiming that she was being controlled by electrical impulses beamed across the city by "authoritarian capitalists". She spent hours in the bath, cleaning herself.

Following her removal to an asylum, her parents arrived to collect her possessions. Nearly all of her (mostly clean) clothes were deemed so "soiled" they would need to be burnt. The room was obsessively cleaned. Her father was a health inspector.

Within the medical model of mental illness, she had inherited genes predisposing her to obsessive rituals and to psychosis. The model does not entertain the possibility that the health inspector's intrusiveness distressed her or, as it turned out, that he had sexually abused her.

Yet 13 studies find that more than half of schizophrenics suffered childhood abuse. Another review of 23 studies shows that schizophrenics are at least three times more likely to have been abused than non-schizophrenics. It is becoming apparent that abuse is the major cause of psychoses. It is also all too clear that the medical model is bust.

In the press release accompanying publication of DSM-5, David Kupfer, who oversaw its creation, states: "We've been telling patients for several decades that we are waiting for biomarkers. We're still waiting." This is an astonishing admission that there are no reliable genetic or neurological measurements that distinguish a person with mental illness.

While there is some evidence that the electro-chemistry of distressed people can be different from the undistressed, the Human Genome Project seems to be proving that genes play almost no part in causing this. Eleven years of careful study of our DNA shows that differences in it do not explain mental illness, hardly at all. If one sibling is anxious or depressed and another is not, at most, differences in DNA can only explain 1-5% of why it is one and not the other.

Of course, some researchers maintain that, given more time (and money), they will still come up with significant results. But off the record, nearly all molecular geneticists admit that it now really does look as if differences in DNA will explain very little.

By contrast, there is a huge body of evidence that our early childhood experiences combined with subsequent exposure to adversity explain a very great deal. This is dose dependent: the more maltreatment, the earlier you suffer it and the worse it is, the greater your risk of adult emotional distress. These experiences set our electro-chemical thermostats.

So does subsequent adult adversity. For instance, a person with six or more personal debts is six times more likely to be mentally ill than someone with none, regardless of their social class: the more debts, the greater the risk.

We need fundamental changes in how our society is organised to give parents the best chance of meeting the needs of children and to prevent the amount of adult adversity.

Oliver James trained and practised as a clinical psychologist. He is the author of Love Bombing – Reset your Child's Emotional Thermostat


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Upcoming International Conference 05 Apr 2013

The International Neuropsychoanalysis Society is hosting its 14th conference in Cape Town from the 22nd to the 25th of August. The conference is entitled The Clinical Applications of Neuropsychoanalysis and will feature internationally renowned experts such as Jaak Panksepp, Mark Solms, Oliver Turnbull and Katerina Fotopoulou.

The congress is aimed at professionals working with all aspects of mind/brain disorders and development. Neuropsychoanalysis contributes to understanding the mind/brain interface. But what are the practical implications of this understanding for our clinical work, as psychoanalysts and therapists or as neuropsychologists and psychiatrists? Set in the beautiful grounds of the University of Cape Town, this congress will address that question. Come learn about the implications of neuropsychoanalytic research for such diverse clinical topics as conversion disorders, depression, addiction, epilepsy, dementia and focal neuropsychological syndromes (e.g., confabulation). Find out also about the clinical implications of neuropsychoanalysis for conventional psychoanalytic therapy.

CPD points will be provided for both the conference and the education day. Please click on the link below to go to the conference webpage.


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Transcranial Magnetic Stimulation Used to Treat Chronic Pain 17 Mar 2013

Using a new treatment that has shown promising results in alleviating major depression, researchers at Stanford now claimed some success using transcranial magnetic stimulation (rTMS) to treat sufferers of chronic pain.

Until now, pain seemed out of reach for rTMS because the regions involved in pain perception lie very deep within the brain. The other disorders helped by rTMS all involve brain areas close to the skull. To treat depression, for example, a single magnetic coil directs a magnetic field at the dorsolateral prefrontal cortex, a region of the brain's outer folds. When aimed at different areas of these outer folds, rTMS improves the motor symptoms of Parkinson's disease, staves off the damage of stroke, lessens the discomfort that follows nerve injury and treats obsessive-compulsive disorder. The magnetic field affects the electrical signaling used by neurons to communicate, but how exactly it improves symptoms is unclear—scientists suspect rTMS may redirect the activity of select cells or even entire brain circuits.


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Daniel Kahneman On the Experiencing and Remembering Self 12 Feb 2013

Using examples from vacations to colonoscopies, Nobel laureate and founder of behavioral economics Daniel Kahneman reveals how our "experiencing selves" and our "remembering selves" perceive happiness differently. This new insight has profound implications for economics, public policy -- and our own self-awareness. Widely regarded as the world's most influential living psychologist, Daniel Kahneman won the Nobel in Economics for his pioneering work in behavioral economics -- exploring the irrational ways we make decisions about risk.


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Who Will You Be in Ten Years TIme? 18 Jan 2013

Harvard psychologist Dan Gilbert and his team created an online study involving 19 000 people to better understand how well they were able to predict the extent to which they would change in the future. Since many of the major decisions we make will have long lasting consequences, this study seeks to better understand how people make predictions about their future selves.

Although teenagers are notoriously bad at envisioning their future selves ("Of course I'll always want this butterfly tattoo!"), Gilbert says he was surprised that even older people seem to underestimate how much they'll change. For example, 68-year-olds reported modest personality changes in the previous decade, but 58-year-olds predicted very little, if any, change in the coming decade, even though their survey answers indicated that they had changed considerably since they were 48. Several follow-up experiments suggested that these differences reflect errors in predicting the future rather than errors in remembering the past. Gilbert and colleagues call this effect "the end of history illusion," because it suggests that people believe, consciously or not, that the present marks the point at which they've finally stopped changing.

In additional surveys, the researchers found that people similarly underestimate changes in their personal values (things like success and security) and preferences (like their favorite band and best friend). "What these data suggest, and what scads of other data from our lab and others suggest, is that people really aren't very good at knowing who they're going to be and hence what they're going to want a decade from now," Gilbert says.


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New Edition of the DSM Finalised 13 Dec 2012

The DSM-5 has been finalised and is due to go on sale from May next year. Here are some of the responses and commentary in the last week to the changes:

  • Thinking Clearly About Personality Disorders.

    The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.

  • A critical take by Allan Frances who was the chair of the DSM-IV Task Force, DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes.

    New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs- often by primary care doctors after brief visits. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. APA is not competent to do this.

  • Science blogger Vaughan Bell adds his take on the changes: The DSM-5 has been finalised.

  • A detailed monitoring the revisions of both the DSM and ICD can be found at Dx Revision Watch.

    This site has been monitoring the revision processes towards DSM-5 and ICD-11, generally, since the beginning of 2010 and endeavours to provide timely updates and content of interest to consumer groups and professionals who are stakeholders in these classification systems.

  • A concise breakdown to the updated manual here: Final DSM 5 Approved by American Psychiatric Association.

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The Impact of Infant Stress on the Teen Brain 11 Nov 2012

A study published today in Nature Neuroscience contributes to understanding the specific ways in which exposure to early stress affects the connectivity of the maturing brain.

“This is one of the first demonstrations that early stress seems to have an impact on the the way this regulatory circuitry is set up in late adolescence,” says Richard Davidson, a neuroscientist at the University of Wisconsin-Madison and one of the leaders of the study.

The study showed that 18-year-old girls who had had high cortisol levels at age 4 have weak connectivity between the amygdala, a deep nub of the brain known for processing fear and emotions, and the ventromedial prefrontal cortex, an outer region involved in curbing the amygdala’s stress response.

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New South African Fact Checking Organisation 02 Nov 2012

South Africans now have their first fact checking organisation, in the mold of similar initiatives in the US and Europe.

From their website:

Africa Check is an independent, non-partisan organisation which assesses claims made in the public arena using journalistic skills and evidence drawn from the latest online tools, readers, public sources and experts, sorting fact from fiction and publishing the results.

Their team includes the science writer and physician, Ben Goldacre, who we have featured in a previous post.

You can read more about the initiative here.


The Marshmallow Test Revisited 02 Nov 2012

A recent study summarised here, offers an interesting update on the classic Marshmallow Test.

"Coauthor Richard Aslin said that their findings remind us about how complex human behavior is. "This study is an example of both nature and nurture playing a role," he says. "We know that to some extent, temperament is clearly inherited, because infants differ in their behaviors from birth. But this experiment provides robust evidence that young children's actions are also based on rational decisions about their environment."

The Marshmallow Study Revisited from University of Rochester on YouTube.

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On the DSM-5 25 Oct 2012

Often referred to as the bible of psychiatry, the Diagnostic and Statistical Manual of Psychiatry (DSM) will be published in its fifth edition in May next year, once again transforming the way in which mental illness is defined. In this series of five short essays Paul Fitzgerald takes a closer look into the DSM providing a basic introduction to some of the issues.

Psychiatric research indicates that things are more complicated than the manual leads us to believe. In reality, many diagnostic categories overlap. Over the years, many new diagnostic categories have been proposed. As a consequence, many individuals now fit several diagnostic labels. Should their different disorders all be treated separately, or at the same time?

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Debating Free Will 25 Oct 2012

Earlier this year Harvard's Mind, Brain, and Behavior Initiative hosted a fascinating discussion/freewill/) between Dan Dennett, Josh Greene and Steven Pinker on the topic of free will . Be sure to check out some of the other talks on the website.

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Why do children hide by covering their eyes? 25 Oct 2012

Children often think they're hiding when covering their eyes. Researchers at the University of Cambridge attempt to find out why. Be sure to read the rest - it's really interesting.

Now things get a little complicated. In both studies so far, when the children thought they were invisible by virtue of their eyes being covered, they nonetheless agreed that their head and their body were visible. They seemed to be making a distinction between their "self" that was hidden, and their body, which was still visible. Taken together with the fact that it was the concealment of the eyes that seemed to be the crucial factor for feeling hidden, the researchers wondered if their invisibility beliefs were based around the idea that there must be eye contact between two people - a meeting of gazes - for them to see each other (or at least, to see their "selves").


An Autodidact's Dream 08 Oct 2012

Here is a list of courses run by Coursera which may be of interest to some of you. For those of you who don't know, Coursera is a new elearning initiative involving a number of American Universities offering high quality introductory courses in a number of fascinating subjects.

The Marshmallow Test 07 Oct 2012

In this popular test, several kids wrestle with waiting to eat a marshmallow in hopes of a bigger prize. This video is a good illustration of temptation and the hope in future rewards. This experiment is based on many previous and similar scientific tests.

The Marshmallow Test from Igniter Media on Vimeo.

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Weekly Roundup of Posts 24 Sep 2012

The 2012 Bioethics conference on the Moral Brain, featuring Joseph Ledoux and Josh Greene is now online.

An extract from the upcoming new title from Ben Goldacre's new book Bad Pharma Here also is his TED talk.

A new review of retracted articles in biomedical and life-science research finds that 67.4% were due to misconduct.

On schizophrenia as a brain disease link.

A recent piece on the Nature blog calling for further research into improving current psychotherapies.

An interview with science blogger Ed Yong talks about some of the misconceptions of oxytocin.

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  • Karen Franklin reports on a soon to be published study in Law and Human Behaviour, the first of its kind in the US, which examined levels of agreement among independent forensic evaluators in routine legal practice. The study found a surprisingly low level of agreement between evaluators who looked at 483 evaluation reports involving 165 criminal defendants. Read the full post: Sanity opinions show "poor" reliability, study finds

  • A short interview with Professor Vikram, one of the guest editors for the new PLOS Medicine Global Mental Health Series, which "seeks to expand the evidence base of global mental health by publishing case studies of global mental health in practice." Q & A with Vikram Patel. You can read the editorial here: Putting Evidence into Practice: The PLoS Medicine Series on Global Mental Health Practice.

  • Why I am Always Unlucky But You Are Always Careless - Vaughan Bell on the fundamental attribution error.

  • An audio interview with Oliver Burkeman and Jules Evans on the upside of pessimism.

    For Burkeman, a contented life must embrace uncertainty and get friendly with failure. But could the active pursuit of happiness be part of the problem? Evans takes a more can-do approach, looking back to the wisdom of ancient Greek philosophers and tracking it through to the Cognitive Behaviour Therapy of today, which helped him to escape depression in his early 20s. Hear the interview.

  • A moving and entertaining TED Talk by Psychology and Law Professor Elyn Saks on what it is like to live with schizophrenia. Elyn Saks: A tale of mental illness from the inside

(Image by Mattaz)

The Darker Side of Positive Thinking 09 Jul 2012

A beautifully animated film to explore Barbara Ehrenreich ideas on our culture's "mandatory optimism".

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Weekly Roundup of Posts 20 Jun 2012

Weekly Roundup from the Blogosphere:

-A post about wardrobe advice for expert witnesses Bow ties: The simple solution to expert witness credibility by Karen Franklin

-The New York Times report on a recent paper in PLOS which suggest that as many as 1 in 8 of those who survive a heart attack will go on to develop post traumatic stress disorder. Read more: Heart Attack Survivors May Develop P.T.S.D.

-The adverse consequences of exercise. A summary of the article can be found on the New York Times blog is here.

-Short video on what makes a good psychotherapy session

-An amusing post on the social neuroscience of self-reference by science blogger scicurious

-A post about medical health records and confidentiality

-A list of prominent neuroscientists who tweet

(Image by Vacacion)

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Social Media and the Diagnosis of Mental Illness 18 Jun 2012

While much has been written recently about the dangers of internet use, new research seems to suggest a potential role for social media in assisting with the diagnosis of mental disorders. Last week, The Guardian reported on a study done at the University of Leeds where researchers found an association between the frequency and pattern of internet use and depression, and this week theNeurocritic has written an interesting post about how a dramatic increase in texting (not to be confused with hypertexting of course) is a modern version of hypergraphia, which can be a sign for a manic episode.

And certainly the evidence for manic/hypomanic hypergraphia has been plainly obvious for as long as the internet has existed. There are thousands of bipolar bloggers and Tweeters and Facebook users and online journalers before that. Unlike PubMed, Google Blog Search returns 3,670 hits for bipolar hypergraphia and 4,230 hits for manic hypergraphia. And those are just the posts that use the term hypergraphia. One could envision a study on quantitative changes in written output on Twitter or blogs as a possible sign of bipolar cycling.

(Image by Jhaymesisviphotography)


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Growing Rate of Body Dysmorphic and Eating Disorders in the UK Elderly 11 Jun 2012

This article from the Guardian reports on the plight of an increasing number of the elderly plagued by body-image related anxiety.

Even those who are relatively fit and healthy in later years struggled with the idea that they no longer conformed to a youthful ideal, said Rumsey, who recently co-wrote The Oxford Handbook of the Psychology of Appearance. "It is a myth that older people don't care what they look like: the 'normal' signs of ageing can prove very depressing and many people find it hard to see themselves in a positive light when they see a wrinkled face and a sagging body looking back in the mirror. We are now at a point where there is a social stigma around the effects of the natural ageing process, and this can lead to very low self-esteem and the classic signs of body dysmorphic disorder."

(Image: All rights reserved by


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The Overdiagnosis of ADHD in Younger Children 30 May 2012

In his latest post, blogger Neuroskeptic critiques a recent challenge to the "immaturity hypothesis" and points to what may be a common misdiagnosis of ADHD in younger children, who seem relatively immature to their older classmates in the same grade. Earlier this year, a Canadian study of ADHD rates in almost a million children found that children born later in the year were more likely to be diagnosed with ADHD.

This is strong support for the "immaturity hypothesis" - the idea that some children get a diagnosis of ADHD because they're younger than their classmates at school, and their relative immaturity is wrongly ascribed to an illness.


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Coordination Of Client Care During Therapist’s Absence 29 May 2012

A useful blog post by Tamara Suttle for therapists on managing clients during a temporary absence.


Replication in Psychology 18 May 2012

In an excellent blog post on the Nature website, Ed Yong discusses the problem of replication in psychology and the challenges facing those who try to publish negative findings.

Positive results in psychology can behave like rumours: easy to release but hard to dispel. They dominate most journals, which strive to present new, exciting research. Meanwhile, attempts to replicate those studies, especially when the findings are negative, go unpublished, languishing in personal file drawers or circulating in conversations around the water cooler. “There are some experiments that everyone knows don't replicate, but this knowledge doesn't get into the literature,” says Wagenmakers. The publication barrier can be chilling, he adds. “I've seen students spending their entire PhD period trying to replicate a phenomenon, failing, and quitting academia because they had nothing to show for their time.”


Maternal stress and emotional problems in children 15 May 2012

A new study published in the Proceedings of the National Academy of Sciences, links cortisol levels during early pregnancy with increased amygdala volume and emotional problems in children. The study followed 65 mother-child dyads over a 7 year period.

The current findings represent, to the best of our knowledge, the first report linking maternal stress hormone levels in human pregnancy with subsequent child amygdala volume and affect. The results underscore the importance of the intrauterine environment and suggest the origins of neuropsychiatric disorders may have their foundations early in life.

The full text of the paper is available in the link below.


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Social connection and longevity 13 May 2012

In an excerpt from his book Subliminal: How Your Unconscious Mind Rules Your Behavior, popular science writer Leonard MlodInow, writes about the link between our physical health and our connection with others.

Social connection is such a basic feature of human experience that when we are deprived of it, we suffer. Many languages have expressions—such as “hurt feelings”—that compare the pain of social rejection to the pain of physical injury.


Quest for the connectome: scientists investigate ways of mapping the brain 08 May 2012

There is a macabre brilliance to the machine in Jeff Lichtman's laboratory at Harvard University that is worthy of a Wallace and Gromit film. In one end goes brain. Out the other comes sliced brain, courtesy of an automated arm that wields a diamond knife. The slivers of tissue drop one after another on to a conveyor belt that zips along with the merry whirr of a cine projector.

Lichtman's machine is an automated tape-collecting lathe ultramicrotome (Atlum), which, according to the neuroscientist, is the tool of choice for this line of work. It produces long strips of sticky tape with brain slices attached, all ready to be photographed through a powerful electron microscope.

When these pictures are combined into 3D images, they reveal the inner wiring of the organ, a tangled mass of nervous spaghetti. The research by Lichtman and his co-workers has a goal in mind that is so ambitious it is almost unthinkable.


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The Scientific Flaws of Online Dating Sites 08 May 2012

Every day, millions of single adults, worldwide, visit an online dating site. Many are lucky, finding life-long love or at least some exciting escapades. Others are not so lucky. The industry—eHarmony, Match, OkCupid, and a thousand other online dating sites—wants singles and the general public to believe that seeking a partner through their site is not just an alternative way to traditional venues for finding a partner, but a superior way. Is it?

With our colleagues Paul Eastwick, Benjamin Karney, and Harry Reis, we recently published a book-length article in the journal Psychological Science in the Public Interest that examines this question and evaluates online dating from a scientific perspective. One of our conclusions is that the advent and popularity of online dating are terrific developments for singles, especially insofar as they allow singles to meet potential partners they otherwise wouldn’t have met. We also conclude, however, that online dating is not better than conventional offline dating in most respects, and that it is worse is some respects.


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Neuroscience fiction in newpapers 08 May 2012

A recent article in the journal Neuron analysed how neuroscience stories are typically presented by major UK newspapers. Although diplomatically stated in the paper, the findings do not inspire confidence. To summarise, it seems that when neuroscience findings are covered by the mainstream press, they're invariably interpreted in questionable ways in order to support political ideology or predetermined views and theories, up to and including discriminatory stereotypes - for example about homosexuals.

While newspaper stories about neuroscience research usually have some sort of appreciable logic, they typically end up with conclusions or predictions that are well beyond the focus of the original study, and bear little or no resemblance to a scientific critique. (Ironically, the most common category used in what seemed to be an ever increasing flow of misinformation was "Brain optimisation".)